Navigating Electrocardiographic Risk Stratification and Therapeutic Strategies in Acute Coronary Syndrome Without ST-Segment Elevation

Of the patients suffering acute proximal left anterior descending (LAD) artery occlusion, a small but not insignificant minority does not manifest the classical ST-segment elevation myocardial infarction (STEMI) electrocardiographic (ECG) patterns. They manifest junctional upsloping ST-segment depression followed by tall, symmetrical T waves in the precordial leads instead, known as the de Winter pattern. Such patients may suffer a nearly transmural infarct if not managed promptly with percutaneous coronary intervention (PCI). Therefore, they should be treated as suffering a STEMI equivalent. The patient presented here suffered a total proximal “wrap-around” LAD artery in-stent occlusion manifesting the de Winter ECG pattern. The latter, was correctly and promptly recognized and the patient was managed successfully with emergency PCI achieving a good outcome. Discussion pertains to the morphology of ST-segment depression (STD) and the polarity and magnitude of the T waves accompanying STD which provide prognostic information and facilitate risk stratification in patients presenting with non-ST-segment elevation acute coronary syndrome. The pathophysiology underlying the de Winter ECG pattern and the appropriate therapeutic strategy are also discussed. The Littmann concept is also discussed, providing a reliable explanation for the ST-segment elevation observed in a misplaced lead V1.